DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS 0120 PERIODIC ORAL EXAMINATION - ESTABLISHED PATIENT 20 0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED 33 0150 COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT 38 0170 RE-EVALUATION - LIMITED, PROBLEM FOCUSED (ESTABLISHED PATIENT; NOT POST-OPERATIVE 21 VISIT) 0180 COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR ESTABLISHED PATIENT 38 0210 INTRAORAL - COMPLETE SERIES OF RADIOGRAPHIC IMAGES 62 0220 INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE 13 0230 INTRAORAL - PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC IMAGE 10 0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE 19 0270 BITEWING, SINGLE RADIOGRAPHIC IMAGE 13 0272 BITEWINGS, TWO RADIOGRAPHIC IMAGES 20 0274 BITEWINGS, FOUR RADIOGRAPHIC IMAGES 30 0277 VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES 40 0330 PANORAMIC RADIOGRAPHIC IMAGE 55 0340 CEPHALOMETRIC RADIOGRAPHIC IMAGE 60 0460 PULP VITALITY TESTS 26 0470 DIAGNOSTIC CASTS 50 1110 PROPHYLAXIS - ADULT 45 1120 PROPHYLAXIS - CHILD 35 1208 TOPICAL APPLICATION OF FLUORIDE 18 1330 ORAL HYGIENE INSTRUCTIONS No Charge 1351 SEALANT - PER TOOTH 25 1510 SPACE MAINTAINER - FIXED - UNILATERAL 160 1515 SPACE MAINTAINER - FIXED - BILATERAL 230 1520 SPACE MAINTAINER - REMOVABLE - UNILATERAL 190 1525 SPACE MAINTAINER - REMOVABLE - BILATERAL 265 1550 RE-CEMENTATION OF SPACE MAINTAINER 38 2140 AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT 55 2150 AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT 70 2160 AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT 85 2161 AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR PERMANENT 100 2330 RESIN-BASED COMPOSITE - ONE SURFACE, ANTERIOR 65 2331 RESIN-BASED COMPOSITE - TWO SURFACES, ANTERIOR 80 2332 RESIN-BASED COMPOSITE - THREE SURFACES, ANTERIOR 95 2335 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) 125 2391 RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR 75 2392 RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR 90 2393 RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR 115 2394 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR 135 CUT7697-6N (2/13) CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc 1
2 DISCOUNT DENTAL PLAN 2510 INLAY - METALLIC - ONE SURFACE 325 2520 INLAY - METALLIC - TWO SURFACES 410 2530 INLAY - METALLIC - THREE OR MORE SURFACES 475 2543 ONLAY - METALLIC - THREE SURFACES 520 2544 ONLAY - METALLIC - FOUR OR MORE SURFACES 580 2610 INLAY - PORCELAIN/CERAMIC - ONE SURFACE 410 2620 INLAY - PORCELAIN/CERAMIC - TWO SURFACES 450 2710 CROWN - RESIN-BASED COMPOSITE(INDIRECT) 350 2740 CROWN - PORCELAIN/CERAMIC SUBSTRATE 590 2750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 590 2751 CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL 550 2752 CROWN - PORCELAIN FUSED TO NOBLE METAL 570 2790 CROWN - FULL CAST HIGH NOBLE METAL 590 2791 CROWN - FULL CAST PREDOMINANTLY BASE 550 2792 CROWN - FULL CAST NOBLE METAL 570 2799 PROVISIONAL CROWN - FURTHER TREATMENT OR COMPLETION OF DIAGNOSIS NECESSARY PRIOR 250 TO FINAL IMPRESSION 2910 RECEMENT INLAY, ONLAY, OR PARTIAL COVERAGE RESTORATION 50 2920 RECEMENT CROWN 50 2930 PREFABRICATED STAINLESS STEEL CROWN - PRIMARY TOOTH 135 2931 PREFABRICATED STAINLESS STEEL CROWN - PERMANENT TOOTH 135 2933 PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW 135 2940 PROTECTIVE RESTORATION 45 2950 CORE BUILDUP, INCLUDING ANY PINS 130 2951 PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATION 28 2952 POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED 220 2953 EACH ADDITIONAL INDIRECTLY FABRICATED POST - SAME TOOTH 110 2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN 160 2957 EACH ADDITIONAL PREFABRICATED POST- SAME TOOTH 80 3110 PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION) 25 3120 PULP CAP - INDIRECT (EXCLUDING FINAL RESTORATION) 22 3220 THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)- REMOVAL OF PULP CORONAL TO 90 THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT 3230 PULPAL THERAPY (RESORABABLE FILLING) - ANTERIOR, PRIMARY TOOTH (EXCLUDING FINAL 100 RESTORATION) 3240 PULPAL THERAPY (RESORABABLE FILLING) - POSTERIOR, PRIMARY TOOTH (EXCLUDING FINAL 125 RESTORATION) 3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION) 420 3320 ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL RESTORATION) 525 3330 ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION) 650 3332 INCOMPLETE ENDODONTIC THERAPY; INOPERABLE, UNRESTORABLE OR FRACTURED TOOTH 275 3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - ANTERIOR 500 3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - BICUSPID 590 3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - MOLAR 700 3410 APICOECTOMY/PERIRADICULAR SURGERY - ANTERIOR 40 3421 APICOECTOMY/PERIRADICULAR SURGERY - BICUSPID (FIRST ROOT) 450
3 DISCOUNT DENTAL PLAN 3425 APICOECTOMY/PERIRADICULAR SURGERY - MOLAR (FIRST ROOT) 500 3426 APICOECTOMY/PERIADICULAR SURGERY (EACH ADDITIONAL ROOT) 200 3430 RETROGRADE FILLING - PER ROOT 140 3450 ROOT AMPUTATION - PER ROOT 195 3910 SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH RUBBER DAM 125 3920 HEMISECTION (INCLUDING ROOT REMOVAL),NOT INCLUDING ROOT CANAL THERAPY 210 4210 GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED 360 SPACES PER QUADRANT 4211 GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED 210 SPACES PER QUADRANT 4212 GINGIVECTOMY OR GINGIVOPLASTY TO ALLOW ACCESS FOR RESTORATIVE PROCEDURE, 210 PER TOOTH 4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETH OR 450 TOOTH BOUNDED SPACES PER QUADRANT 4249 CLINICAL CROWN LENGTHENING - HARD TISSUE 350 4260 OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) - FOUR OR MORE CONTIGUOUS TEETH 675 OR TOOTH BOUNDED SPACES PER QUADRANT 4263 BONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANT 600 4264 BONE REPLACEMENT GRAFT - EACH ADDITIONAL SITE IN QUADRANT 300 4270 PEDICAL SOFT TISSUE GRAFT PROCEDURE 450 4273 SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES, PER TOOTH 500 4274 DISTAL OR PROXIMAL WEDGE PROCEDURE (WHEN NOT PERFORMED IN CONJUNCTION WITH 260 SURGICAL PROCEDURES IN THE SAME ANATOMICAL AREA) 4277 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE SURGERY), FIRST TOOTH OR 490 EDENTULOUS TOOTH POSITION IN GRAFT 4278 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE SURGERY), EACH ADDITIONAL 340 CONTIGUOUS TOOTH OR EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE 4320 PROVISIONAL SPLINTING - INTRACORONAL 200 4321 PROVISIONAL SPLINTING - EXTRACORONAL 150 4341 PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT 125 4342 PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH PER QUADRANT 90 4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSIS 100 4910 PERIODONTAL MAINTENANCE 75 5110 COMPLETE DENTURE - MAXILLARY 700 5120 COMPLETE DENTURE - MANDIBULAR 700 5130 IMMEDIATE DENTURE - MAXILLARY 775 5140 IMMEDIATE DENTURE - MANDIBULAR 775 5211 MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND 600 TEETH) 5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS 600 AND TEETH) 5213 MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES 750 (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) 5214 MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES 750 (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) 5281 REMOVABLE UNILATERAL PARTIAL DENTURE - ONE PIECE CAST METAL (INCLUDING CLASPS AND 375 TEETH) 5410 ADJUST COMPLETE DENTURE - MAXILLARY 42 5411 ADJUST COMPLETE DENTURE - MANDIBULAR 42
DISCOUNT DENTAL PLAN 5421 ADJUST PARTIAL DENTURE - MAXILLARY 42 5422 ADJUST PARTIAL DENTURE - MANDIBULAR 42 5510 REPAIR BROKEN COMPLETE DENTURE BASE 100 5520 REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE (EACH TOOTH) 80 5610 REPAIR RESIN DENTURE BASE 80 5620 REPAIR CAST FRAMEWORK 95 5630 REPAIR OR REPLACE BROKEN CLASP 90 5640 REPLACE BROKEN TEETH - PER TOOTH 80 5650 ADD TOOTH TO EXISTING PARTIAL DENTURE 95 5660 ADD CLASP TO EXISTING PARTIAL DENTURE 95 5710 REBASE COMPLETE MAXILLARY DENTURE 280 5711 REBASE COMPLETE MANDIBULAR DENTURE 280 5720 REBASE MAXILLARY PARTIAL DENTURE 270 5721 REBASE MANDIBULAR PARTIAL DENTURE 270 5730 RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) 180 5731 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) 180 5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) 170 5741 RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) 170 5750 RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) 220 5751 RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) 220 5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) 210 5761 RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) 210 5810 INTERIM COMPLETE DENTURE (MAXILLARY) 300 5811 INTERIM COMPLETE DENTURE (MANDIBULAR) 300 5820 INTERIM PARTIAL DENTURE (MAXILLARY) 275 5821 INTERIM PARTIAL DENTURE (MAANDIBULAR) 275 5850 TISSUE CONDITIONING, MAXILLARY 80 5851 TISSUE CONDITIONING, MANDIBULAR 80 6210 PONTIC - CAST HIGH NOBLE METAL 590 6211 PONTIC - CAST PREDOMINANTLY BASE METAL 550 6212 PONTIC - CAST NOBLE METAL 570 6240 PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL 590 6241 PONTIC - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL 550 6242 PONTIC - PORCELAIN FUSED TO NOBLE METAL 570 6545 RETAINER - CAST METAL FOR RESIN BONDED FIXED PROSTHESIS 325 6750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 590 6751 CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL 550 6752 CROWN - PORCELAIN FUSED TO NOBLE METAL 570 6780 CROWN - 3/4 CAST HIGH NOBLE METAL 590 6790 CROWN - FULL CAST HIGH NOBLE METAL 590 6791 CROWN - FULL CAST PREDOMINANTLY BASE METAL 550 6792 CROWN - FULL CAST NOBLE METAL 570 6940 STRESS BREAKER 275 6950 PRECISION ATTACHMENT 375 4
DISCOUNT DENTAL PLAN 7111 EXTRACTION, CORONAL REMNANTS - DECIDIOUS TOOTH 65 7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) 70 7210 SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF 135 TOOTH, AND EXCLUDING ELEVATION OF MUCOPERIOSTEAL FLAP IF INDICATED 7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE 160 7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY 200 7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY 250 7241 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS 300 7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PRCEDURE) 140 7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH 300 7286 BIOPSY OF ORAL TISSUE - SOFT 140 7310 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH 130 SPACES, PER QUADRANT 7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH 200 SPACES, PER QUADRANT 7510 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE. 100 7520 INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE 100 7960 FRENULECTOMY ALSO KNOWN AS FRENECTOMY OR FRENOTOMY - SEPARATE PROCEDURE NOT 200 INCIDENTAL TO ANOTHER 7971 EXCISION OF PERICORONAL GINGIVA 120 8010 LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION 800 8020 LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DETENTION 900 8030 LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT DETENTION 1000 8040 LIMITED ORTHODONTIC TREATMENT OF THE ADULT DENTITION 1000 8050 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY DETENTION 1100 8060 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DETENTION 1200 8070 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DETENTION 3000 8080 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DETENTION 3000 8090 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DETENTION 3000 8210 REMOVABLE APPLIANCE THERAPY 550 8220 FIXED APPLIANCE THERAPY 480 8660 PRE-ORTHODONTIC TREATMENT VISIT 170 8670 PERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF CONTRACT) 100 8680 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF 300 RETAINER(S) 9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN, MINOR PROCEDURE 50 9230 INHALATION OF NITROUS OXIDE / ANXIOLYSIS, ANALGESIA 40 9241 INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - FIRST 30 MINUTES 200 9242 INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - EACH ADDITIONAL 15 MINUTES 75 9310 CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN 65 REQUESTING DENTIST OR PHYSICIAN 9400 BROKEN APPOINTMENT CHARGE - PER 15 MINUTES (WITHOUT 24 HOURS PRIOR NOTICE) 10 9910 APPLICATION OF DESENSITIZING MEDICAMENT 20 9911 APPLICATION OF DESENSITIZING RESIN FOR CERVICAL AND/OR ROOT SURFACE, PER TOOTH 20 9940 OCCLUSAL GUARD, BY REPORT 325 9951 OCCLUSION ADJUSTMENT - LIMITED 100 9952 OCCLUSION ADJUSTMENT - COMPLETE 320 9974 INTERNAL BLEACHING - PER TOOTH 5 200
Plan Limitations In-Network The following exclusions and limitations shall apply: DISCOUNT DENTAL PLAN n Services for injuries and conditions which are covered under Workers Compensation or Employers Liability Laws; n Services which are provided without cost to the Covered Individual by any municipality, county or other political subdivision (with the exception of Medicaid); n Services which, in the opinion of the participating DENTIST, are not necessary for the Covered Individual s health; n Payment of any claim or bill will not be made for prohibited referrals; n Cosmetic, elective, or aesthetic dentistry, which in the opinion of the participating DENTIST are not necessary for the patient s dental health; n Oral surgery requiring the setting of fractures or dislocations; n Services with respect to malignancies, cysts or neoplasms, or hereditary, congenital or developmental malformations; n Dispensing of drugs, except those used as a local anesthetic; n Hospitalization for any dental procedure; n Loss or theft of bridgework or dentures previously supplied under the PLAN; n Replacement of a bridge, crown, or denture within five (5) years after the date it was originally installed; n Any implantation; n General anesthesia; n Services that cannot be performed because of the general health of the patient; n Teeth Cleaning (Prophylaxis) limited to twice per Contract Term (or Coverage Period); n Unlisted procedures will be provided at the dentist s usual and customary fees; n Services which are obtained outside the dental office in which enrolled and which are not pre-authorized by the PLAN. This does not apply to out-of-area emergency dental services; n Services rendered by a Pedodontist (Pediatric Dentist) are considered Specialty Care and must be approved by the Covered Individual s General Participating DENTIST; n All services listed on the Schedule of Benefits and Member Copayments will be provided by a general Participating Dentist or an approved Specialist; provided, however, that a general DENTIST will refer the Covered Individual or Dependent to an approved Specialist or recommend that the Covered Individual or Dependent contact an approved Specialist if it is the judgment of the DENTIST that the service or procedure must be provided by an approved Specialist, with an exception for out-of-area emergency care; n Services which cannot be performed in the dental office of the Personal Participating DENTIST or Approved Specialist due to the special needs or health related conditions of the Covered Employee and/or Dependent(s). ALL PRICES ARE EXCLUSIVE OF GOLD 6